Early in my surgical training, I found the thought of having a career that affects not only clinical surgery, but also broader issues in the way health care is delivered, to be very appealing. Therefore, during surgical training, I received funding for a VA Special Fellowship in Outcomes Research to complete two years of training in health services research, and concurrently obtained a Master's Degree in Evaluative Clinical Sciences from The Dartmouth Institute (TDI). Now, as an assistant professor at Dartmouth in vascular surgery, I have some research experience, especially in the use of observational datasets to measure and predict surgical risk. However, I believe that this Award will help me to grow and achieve important short and long-term goals in building a lifelong research career. First, in terms of short term goals, this Award will expand my ability to measure the effects of variation in treatment in patients with lower extremity peripheral arterial disease (PAD). Second, my long term goal is to become a leader in vascular outcomes research, with a focus on designing clinical pathways and health policy aimed at helping patients make the best treatment choices. The ultimate goal of my research career will be to ensure that patients with vascular disease are well informed about the risks and benefits of different treatment strategies, so that they can make well-informed treatment choices. Three key elements of my career development plan will foster my efforts towards achieving these goals. First, through coursework in advanced observational statistical methods, I will ensure that I strengthen my ability to perform high-quality comparative effectiveness studies of competing treatments and strategies in lower extremity PAD. Second, through coursework in cost analysis, I will develop new expertise in cost measurement in health care. And third, I will use project-based learning to ensure that the didactic elements of my career development plan translate into action. For three reasons, TDI represents an ideal environment to pursue my research agenda. First, for over 20 years, TDI has been recognized as a national leader in studying health care delivery and effectiveness. TDI has produced national leaders in the evaluation of regional variation in the delivery and quality of care, outcomes analysis, and shared-decision-making. Second, I am fortunate to have the mentorship of one of TDI's leaders, Dr. Elliott Fisher. He has served as a mentor since my time as a VA Outcomes Fellow in 2002, continually through our recent efforts in measuring regional variation. And, third, TDI has developed a close relationship with the Vascular Study Group of New England, a regional quality improvement initiative centered at the Section of Vascular Surgery at Dartmouth. The VSGNE has served as a platform for piloting our work in linking clinical datasets to administrative data, as well as refining and testing our administrative prediction models with clinical data. My research project will examine the effect of variation in vascular treatment intensity on PAD-specific outcomes. Lower extremity peripheral arterial disease (PAD) affects over 12 million Americans, and results in nearly 100,000 major amputations (above or below-knee) annually in the United States. However, the risk of amputation from PAD varies ten-fold, depending on where patients reside. Research in the Dartmouth Atlas of Health Care has attributed some of these regional differences in amputation to patient-level factors, reporting five-fold higher amputation rates among blacks and those of low socioeconomic status (SES). However, such significant variation in amputation rates cannot be explained solely by patient factors; health care delivery to these patients varies significantly as well. Our preliminary work shows sizeable disparities in the intensity of vascular care received by patients in the year before they undergo major lower extremity amputation. These differences suggest that in some regions, far too little vascular care is being provided. In other regions, very intensive vascular care, with aggressive use of invasive revascularization procedures, may not necessarily translate into better outcomes for patients. Efforts to improve vascular care for patients with PAD will require better knowledge of the variation in intensity of care and its relationship to PAD-specific outcomes. In this proposal, I will characterize variation in the treatment of lower extremity PAD, explore the determinants of this variation, and study the relationship of intensity of vascular care to PAD-related outcomes. This project will inform my future research, aimed at better targeting the use of vascular care to achieve optimal outcomes in patients with lower extremity PAD.